Vascular and Intestinal Anastomotic Workshop

Name the InstrumentsPGY 1

Name the InstrumentsPGY 1

Name the InstrumentsPGY 1

Commonly used SuturesBraided? Absorbable? Timeline # of throws

Silk Braided no n/a 3-4

Vicryl Braided yes 55-70 days 4-5

Prolene Mono no n/a 6-8

Chromic Mono yes 90 days 4-5

PDS Mono yes 180-210 days 6-8

Nylon Mono no n/a ~5

Gore Mono no n/a ~8

Monocryl Mono yes 90-120 days 5

PGY 1

Lembert Sutures

• Definition?• Reason?

PGY 2

Connell Sutures

• Describe Connell suturing technique

PGY 2

Staplers

Name the StaplerPGY 2

Name the Stapler…PGY 2

Name the StaplerPGY 2

Side to side anastomosis

• How do you set up a side to side anastomosis?

CRITICAL CONCEPTS• Non-tension• GIA stapler• Align anti-mesenteric

sides of bowel together• Staggered staple lines

PGY 2

End-to-end Anastomosis

• How do you set up a stapled end-to-end anastomosis?

PGY 2

Functional End-to-end anastomosis

• Describe another way to perform a stapled end to end anastoamosis

PGY 2

Stapler Loads• What is the difference

between the different stapler loads?

• What color load do

you use for vascular tissue? Stomach? Small bowel? Colon? Rectum?

PGY 3

Hand Sewn Anastomosis

• Describe the different types of suture techniques used in hand sewn bowel anastomosis

PGY 3

Hand Sewn Anastomosis

• Describe the steps for a 2 layer anastomosis

PGY 3

Hand Sewn Anastomosis

• Describe how to sew a single layer anastamosis

PGY 3

Arm Vascular Anatomy

• Describe the arterial and venous blood flow to the arm

PGY 2

Types of Surgical Dialysis Access

• What is the difference between an AV Fistulae and an AV Graft

PGY 2

Sites for AV fistulae

Radiocephalic AV Fistula

Brachiocephalic AV graft

Basilic Vein Transposition

DRIL procedure

• DRIL = Distal Revascularization Interval Ligation

• RUDI = Revision Using Distal Inflow

Vascular Anastomosis

• Identify autogenous materials for vascular anastomosis: – Saphenous vein, iliac vein

• Identify exogenous materials for vascular anastomosis: – bovine pericardium, ePTFE, gore-tex, cadaveric

• What is the dosing/timing for heparinization during a vascular anastomosis? – 75-100 units/kg, given 5 minutes prior to vascular occlusion

• How do you measure heparinization to confirm appropriate levels have been achieved? – Activated clotting time (ACT) of greater than 250

PGY 3

Zones of Retroperitoneum• Describe the Zones of the retroperitoneum

and the major vasculature that could be injured in each zone

• Zone 1: Midline retroperitoneum– Supramesocolic region (suprarenal aorta,

celiac, SMA/SMV, proximal renal artery)– Inframesocolic region (infrarenal aorta,

infrarenal IVC)• Zone 2: Upper lateral retroperitoneum

(renal artery/vein)• Zone 3: Pelvic retroperitoneum (iliac

artery/vein)

PGY 3

Zone I Great Vessel Injury

• Describe the approach for supramesocolic Zone I injuries: – Left medial visceral

mobilization– May also need to

transect the left crus (at 2o’clock position) to allow for control of the descending thoracic aorta

PGY 3

Zone I Great Vessel Injury

• Describe the approach for inframesocolic Zone I injuries:– Lift up on transverse mesocolon,

eviscerate small bowel to right, open mid-line retroperitoneum and cross clamp the aorta inferior to the left renal vein

– For IVC injuries, perform a right medial visceral mobilization (right colon and duodenum), leaving the kidney in situ

PGY 3

Zone I Great Vessel Injury

• Describe the approach to an inframesocolic Zone I injury to the IVC at the common iliac vein confluence: – After right medial visceral mobilization, it may be

necessary to divide and ligate the right internal iliac artery or to temporarily divide the right common iliac artery

PGY 3

Zone I Great Vessel Injury

• Describe the approach to an inframesocolic Zone I injury to the IVC at the level of the renal veins:– After right medial visceral mobilization, you should

clamp/compress the IVC proximally and distally and loop/clamp both the left and right renal veins. It may be necessary to perform a medial mobilization of the right kidney (watch out for 1st lumbar vein!)

PGY 3